Registered Nurse Case Manager
Resume:
Stephanie Nicole Hill
Supplier Notes:
**+ years of experience as Registered Nurse.
Extensive experience in Home Health, Case Management and Utilization Management.
Experienced in MCG, Managed Care, HMO, PMG, Appeals and Grievance Charting and compliance auditing.
Worked closely with PMG/HMO's, Prepared clinical reviews and provides monitoring of cases involving medical decisions and quality or care or service.
Participated in documentation of authorization, addressing concurrent denials, payor related communication, mitigating denials and setting up peer-to-peer review.
Prepared recommendations to either uphold or deny appeal and forwards to Medical Director for approval, Ensured that appeals and grievances are resolved timely to meet regulatory timeframes.
Utilization of Milliman/MCG Care Guidelines to complete initial and continued stay reviews in determining appropriate level of patient care.
Skills - EMR Systems, Microsoft applications and ICD 10 Coding.
Carries an active registered-nurse license in CA.
Candidate will work remotely.
Excellent communication and interpersonal skills.
Summary:
15 years of clinical and case management experience as a Registered Nurse.
Professional Experience:
RN Utilization Management Case Manager RN
Kaiser Permanente - Riverside, CA
January 2019 to Present
Concurrent Review. Coordinates and facilitates the process of inpatient admissions, authorizations and eligibility for In-patient admissions to the appropriate level of care. Processes or obtain authorizations/certifications based on payer contracts. Utilization of Milliman/MCG Care Guidelines to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of test/procedures and an estimation of the patients expected length of stay. Participate in documentation of authorization, addressing concurrent denials, payor related communication, mitigating denials and setting up peer-to-peer reviews.
Telemetry and Step down Case Manager/Utilization Review/Concurrent Review
Loma Linda University Medical Center
August 2017 to January 2019
Coordinates and facilitates the process of patient admissions, authorizations and eligibility for In-patient admissions to the appropriate level of care. Processes or obtain authorizations/certifications based on payer contracts. Utilization of MCG Care Guidelines to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of test/procedures and an estimation of the patients expected length of stay. Participate in documentation of authorization, addressing concurrent denials, payor related communication, mitigating denials and setting up peer-to-peer reviews.
Senior Clinical Appeals and Grievance RN
HealthNet - Woodland Hills, CA
May 2016 to August 2017
Worked closely with PMG/HMO's, Prepared clinical reviews and provides monitoring of cases involving medical decisions and quality or care or service, Screened cases in rotation/triage to ensure it meets standard or expedited services, Reviewed all assigned cases, Overturn or uphold 75% of cases or send to doctor for determination, Head of New Work Flows - team of 56, Expedited pre-service Appeals inpatient and outpatient, SNF/AIR/LTACH appeals and ensured all cases are completed in accordance with State and Federal regulatory requirements for timelines, Met timeframes for performance with balancing the need to produce high quality work and resolving complex and sensitive member issues, Ensured integrity of departmental database and recording maintenance by thorough, timely and accurate entry of cases assigned, Assists with analyzing and reporting of cases through the GARS Subcommittee and Participated in departmental meetings, trainings and audits as requested.
Per Diem and Registry Registered Nurse and Case Manager
Precision Nursing Service - Eastvale, CA
May 2014 to December 2016
Coordinated and facilitated the process of patient admissions, authorizations and eligibility for In-patient admissions to the appropriate level of care and patients got cost effective outcomes and quality care. As a registry and travel Case Manager. Collaborated with members of the health care team, the patient and their family, to assure effective, efficient and appropriate care and outcomes. Was always knowledgeable of the criteria for medical necessity for each level of care through the continuum of care and was able to articulate clinical information to payers, to assure appropriate reimbursement. Worked closely with physicians, staff and patients throughout the continuum of care to ensure that an appropriate level of care was achieved.
Senior Appeals and Grievances Nurse UM
United Healthcare - Cypress, CA
March 2011 to November 2015
Won multiple awards and bonuses for outstanding performance, award in October 2013 for above average productivity of 180%, Conducted investigations and reviews of member and provider medical necessity appeals, Reviewed prospective, inpatient, or retrospective medical records of denied services for medical necessity, Extrapolated and summarized medical information for medical director, consultants and other external review, Prepared recommendations to either uphold or deny appeal and forwards to Medical Director for approval, Ensured that appeals and grievances are resolved timely to meet regulatory timeframes, Documented and logged appeal/grievance information on relevant tracking systems and mainframe systems, Generated written correspondence to providers, members and regulatory entities, Utilized leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues, .Investigated and processed the most complex grievances and appeals requests from members and providers and Served as technical resource to team and may be assigned to work on projects impacting development, interpretation and implementation of medical policy or other managed care initiatives.
Education:
Associate Degree in Nursing in Nursing
Career College of America - Ontario, CA
2010
Nursing Licenses
RN
Expires: April 2020
State: CA
Skills:
Utilization review
Managed care
Medicare
Claims
Charting
Cerner
Meditech
Epic
Oasis
Therapeutic
User experience
Healthcare
Home Health
RN
Home Care
Care Management
Case Management
Nursing
EMR Systems
Botox Experience
Utilization Management
Dermal Fillers
Botox
Triage
Hospital Experience
Medical Records
ICD-10
Employee Orientation
Certifications and Licenses:
BLS Certification
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